Brian Jacob, MD Brian Jacob, MD FACSFACSAssistant Clinical Professor of Assistant Clinical Professor of

SurgerySurgeryMount Sinai Medical CenterMount Sinai Medical CenterDirector of the BaricenterDirector of the Baricenter

Laparoscopic Surgical Center of Laparoscopic Surgical Center of New YorkNew York

Not your average inguinal hernia

recurrence

DisclosuresDisclosures

Consultant / Teaching: CovidienConsultant / Teaching: Covidien Consultant : GoreConsultant : Gore Consultant: Ethicon Endo, IncConsultant: Ethicon Endo, Inc

Remember IndicationsRemember Indications

Patients just want their hernias fixed with minimal morbidity

Recipe for SuccessRecipe for Success

Recurrences: Recurrences: Retroperitoneal fixation Retroperitoneal fixation

issues?issues?

Recurrences: Recurrences: Medial fixation issues?Medial fixation issues?

Inguinal hernia Inguinal hernia recurrence:recurrence:

How common?How common?

Recurrent Inguinal Recurrent Inguinal HerniaHernia

Where?Where? LateralLateral

Internal ringInternal ring MedialMedial

Interstitial hernia – between mesh and pubisInterstitial hernia – between mesh and pubis Direct spaceDirect space

InferiorInferior Under the edge of the meshUnder the edge of the mesh

Fixed (sutured) in LichtensteinFixed (sutured) in Lichtenstein Unfixed in laparoscopic approachUnfixed in laparoscopic approach

Courtesy Dr. Bachman

Medial recurrence after Medial recurrence after TEPTEP

TAPP to repair medial TAPP to repair medial recurrencerecurrence

Courtesy: Dr. A Vine

Recurrence: try to Recurrence: try to minimize riskminimize risk

Recurrence: try to Recurrence: try to minimize riskminimize risk

Polyester mesh with polylactic acid microhooks

Recurrent Inguinal Hernia:Recurrent Inguinal Hernia:What technique should you What technique should you

use?use? 82 patients 82 patients (recurrences following open repairs)(recurrences following open repairs)

Giant scrotal hernias excludedGiant scrotal hernias excluded Randomly assigned toRandomly assigned to

TAPP (24) [Group A]TAPP (24) [Group A] TEP (26) [Group B]TEP (26) [Group B] Open Lichtenstein (32) [Group C]Open Lichtenstein (32) [Group C]

Followed post-operatively for 3 yearsFollowed post-operatively for 3 years Primary outcomesPrimary outcomes

PainPain Return to normal activities (professional or Return to normal activities (professional or

otherwise)otherwise)

Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study . Dedemadi G, Sgourakis G, Karaliota C etal. Surg Endosc. 2006 Jul;20(7):1099-104

Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study . Dedemadi G, Sgourakis G, Karaliota C etal. Surg Endosc. 2006 Jul;20(7):1099-104

(TAPP) (TEP) (OPEN)

*

* Statistical significance would require 155 in each arm)

1) Significantly less pain laparoscopically2) No significant differences in recurrence rates at 3 yrs.

TAPP TEP OPEN

Risks associated with GIANT inguinal Risks associated with GIANT inguinal hernia repairs hernia repairs

(informed consent)(informed consent) RRespiratory (cardiopulmonary)espiratory (cardiopulmonary) EEnterotomy (early or late)nterotomy (early or late) CCord injuryord injury

Ischemic orchitisIschemic orchitis UUrinaryrinary RRecurrenceecurrence SSeroma / Hematomaeroma / Hematoma InfectionInfection PainPain

Unique CasesUnique Cases

Giant indirect recurrence after lap Giant indirect recurrence after lap TEPTEP Video case reportVideo case report

Unique CasesUnique Cases

Giant Inguinal ScrotalGiant Inguinal Scrotal

Challenging surgical management Challenging surgical management of a giant inguinoscrotal hernia: of a giant inguinoscrotal hernia:

report of a casereport of a case Giant inguinoscrotal hernia, which extended below Giant inguinoscrotal hernia, which extended below

the patient's kneesthe patient's knees +/- Patient conditioning+/- Patient conditioning +/- Preoperative pneumoperitoneum over 18 days+/- Preoperative pneumoperitoneum over 18 days +/- Debulking the massive hernia contents+/- Debulking the massive hernia contents

right hemicolectomy and transverse colectomyright hemicolectomy and transverse colectomy Others have also reported omentectomy and tensor fasciae latae flapOthers have also reported omentectomy and tensor fasciae latae flap

Mehendal FV, , Taams KO, , Kingsnorth AN Br J Plast Surg. 2000 Sep;53(6):525 2000 Sep;53(6):525

repositioning of the small bowel into the abdominal cavityrepositioning of the small bowel into the abdominal cavity resection of the giant hernia sacresection of the giant hernia sac plastic reconstruction of the penis and scrotal region. plastic reconstruction of the penis and scrotal region.

Mesh RepairMesh Repair

Vasiliadis K, Knaebel HP, Djakovic N, Nyarangi-Dix J, Schmidt J, Büchler M. Surg Today. 2010 Jul;40(7):684-7. (Germany)

Complex inguinal hernia Complex inguinal hernia repairsrepairs

open procedure-Nyhus and Stoppa open procedure-Nyhus and Stoppa (95%) (95%)

Laparoscopic TAPP or TEP (5%)Laparoscopic TAPP or TEP (5%) 255 inguinal hernia repairs255 inguinal hernia repairs

““Progressive preoperative Progressive preoperative pneumoperitoneum for giant hernias pneumoperitoneum for giant hernias was shown to be an important factor in was shown to be an important factor in accomplishing good intraoperative and accomplishing good intraoperative and immediate postoperative results”immediate postoperative results”

Beitler JC, Gomes SM, Coelho AC, Manso JE Hernia. 2009 Feb;13(1):61-6.

Pre-operative Pre-operative PneumoperitoneumPneumoperitoneum

first introduced in 1940first introduced in 1940 port in the subcutaneous position port in the subcutaneous position (first (first

described in 1996 by Naslund, Backman, Melcher of described in 1996 by Naslund, Backman, Melcher of Sweden)Sweden)

air can be injected every few daysair can be injected every few days insufflations performed until the patient insufflations performed until the patient

complains of some mild discomfortcomplains of some mild discomfort can provide additional intraperitoneal can provide additional intraperitoneal

space at time of definitive repair and can space at time of definitive repair and can test the patient’s pulmonary reservestest the patient’s pulmonary reserves

Preoperative progressive Preoperative progressive pneumoperitoneum for giant pneumoperitoneum for giant

inguinal herniasinguinal hernias

Piskin T, Aydin C, Barut B, Dirican A, Kayaalp C. Ann Saudi Med. 2010 Jul-Aug;30(4):317-20, Turkey

Outcomes of giant inguinoscrotal Outcomes of giant inguinoscrotal hernia repair with local lidocaine hernia repair with local lidocaine

anesthesiaanesthesia 134 patients with 136 giant 134 patients with 136 giant

inguinoscrotal hernias were repaired inguinoscrotal hernias were repaired open technique using lidocaineopen technique using lidocaine 10 (7.5%) patients who had incarceration-10 (7.5%) patients who had incarceration-

required sedation, none needed generalrequired sedation, none needed general Scrotal hematoma(13.5%)Scrotal hematoma(13.5%) Wound infection (4.5%)Wound infection (4.5%) No recurrence with 1-5 years follow-upNo recurrence with 1-5 years follow-up

Osifo O, Amusan TI. Saudi Med J. 2010 Jan;31(1):53-8.

Recurrence: SummaryRecurrence: Summary

Prevention is keyPrevention is key If original hernia was done openIf original hernia was done open

Proceed with TEP or TAPPProceed with TEP or TAPP If original hernia done TEP or TAPPIf original hernia done TEP or TAPP

Proceed with TAPP or open (or hybrid)Proceed with TAPP or open (or hybrid) Choice will depend on your experienceChoice will depend on your experience

Recurrence: SummaryRecurrence: Summary

Plan aheadPlan ahead Long discussion with patientLong discussion with patient Optimize patient (smoking, exercise, Optimize patient (smoking, exercise,

respiratory)respiratory) Imaging (Ctscan)Imaging (Ctscan) Decide on anesthesiaDecide on anesthesia Decide if LOD a factor, if so consider Preop Decide if LOD a factor, if so consider Preop

PneumoPneumo Avoid resection of viscera if possibleAvoid resection of viscera if possible Choose repair method most comfortable withChoose repair method most comfortable with

Thank youThank you